Universal Sompo General Insurance Co. Ltd.

Servicing Office of Insurer: DOOR NO:47-1,GROUND FLOOR, OPPOSITE TO, IDBI

BANKDR.BALASUNDARAM ROAD, COIMBATORE, Coimbatore, Tamil Nadu (State Code:33) -641018,
PH-422-2221153 Website: www.universalsompo.com
PAN: AAACU8917F . GSTIN: 33AAACU8917F1ZD Insurer's IRDA Registration Number: 134
Tollfree Helpline 1800-200-4030 Email: [email protected] CIN :
U66010MH2007PLC166770
Passenger carrying Vehicle Package Policy (UIN-IRDAN134RP0004V02200708)
(FORM 51 OF THE CENTRAL MOTOR VEHICLE RULES, 1989)

Policy No. 2311/64957687/00/000 Policy Issued On 20-NOV-2021 (16:43)

Insured Name MRS. VINOTHINI R
Own Damage Period 22-NOV-2021(00:00) To 21-NOV-2022(Midnight) Motor Liability Period 22-NOV-2021(00:00) To 21-NOV-2022(Midnight)

Proposal No. & Date PPVBU10984972, 20-NOV-2021 CPA Cover Period 22-NOV-2021(00:00) To 21-NOV-2022(Midnight)
Insured Add. NO 30 R.R SWAMY LINE , KATTUR , COIMBATORE , TAMIL NADU (State Code:33) -641009
Previous Insurer NIA Previous Policy No. 12220031200350106514 22-NOV-2020 To 21-NOV-2021
Broker Details
IRDA Lic. No.: 375, CIN No.: U50300MH1997PLC149349 Broker Category: Composite Broker, Validity: 13-MAY-20 To 12-MAY-23
Name & Add.: TATA MOTORS INSURANCE BROKING AND ADVISORY SERVICES LTD, 1ST FLOOR, AFL HOUSE, LOK BHARTI COMPLEX, MAROL MAROSHI ROAD,
ANDHERI (EAST), MUMBAI - 400 059

Make Model Sub Model Cubic Capacity Manufacturing Year Seating capacity

TATA MOTORS TIAGO TIAGO XZ 1.2 P 1199 2016 5

Body Type Registration No. RTO Invoice Date Engine No. Chassis No.

HATCHBACK TN 66 T 5793 COIMBATORE 26-OCT-2016 REVTRN02KTYK22934 MAT626281GKK38167

Vehicle IDV CNG/LPG Kit Elec. Accessories Non-Elec. Accessories Total IDV

279,000 0 0 0 279,000

Schedule of Premium (Amount in Rs.)

Own Damage Premium (A)
Basic Premium Deductibles
Vehicle 3,740 Voluntary Deductibles (0) (IMT-22A) 0
Non-Elec. Accessories 0 Anti Theft Device (IMT-10) 0
Elec. Accessories (IMT-24) 0 AA Membership (IMT-8) 0
CNG/LPG Kit (IMT-25) 0 No Claim Bonus (20%) 748
Sub Total (Basic Premium) 3,740 Handicapped Discount (0%) 0
Geographical Area Extension (IMT-1) 0 Sub Total (Deductibles) 748
IMT 23 Premium 0
Add On Coverages (Refer Note 5) 2790
Sub Total-Addition 6530 Net Own Damage Premium (A) 5782
Liability Premium (B)
Basic Third Party Liability 3221 PA Cover For 5 Persons of Rs. 100000 Each (IMT-16) 250
Third Party Liability For Bi-Fuel Kit 0 PA cover for Paid Driver of Rs 2,00,000 (IMT± 0
Third Party Liability For Geographical Area Extension 0 Legal Liability For Paid Driver (IMT-28) 50
PA Cover For Owner Driver Of Rs. 1500000 (IMT-
225 Legal Liability for Employees (for 0 persons) (IMT± 0
15)
Net Liability Premium (B) 3746

Note: 1.Warning that in case of dishonour of the premium cheque, this document stands
automatically cancelled 'ab-initio Total Premium (A+B) 9528
.2.Consolidated stamp duty paid to state exchequer. CGST (9%) 858
3.The policy is subject to compulsory deductible of Rs.1000 (IMT-22) SGST (9%) 858
5.Add-on: DEPRECIATION WAIVER(Nil Depreciation-1 Year:2790)
6.The insurance company will display terms & conditions on its website www.universalsompo.com which
can
be accessed by you online.
*Subject to IMT Endt. Nos.& Memorandum:7,22,16,28
EX-SHOWROOM PRICE : 620000
Gross Premium Paid 11,244

Nominee Details
Name of Nominee Age Relationship with Insured Name of Appointee Relationship with Nominee
RAMESH R 43 SPOUSE --N.A-- --N.A--
Payment Details : Cheque No.: 110338899656, Cheque Date: 20-NOV-2021, Bank Name: PAYLINK, Bank City:
Hypothecation Details: MAHINDRA AND MAHINDRA FINANCIAL SERVICES LTD - COIMBATORE - COIMBATORE
MISP Name: S R TRANZCARS PVT LTD, MISP PAN No: AAUCS5860M, MISP Code: TMIBASL/MISP/AAUCS5860M
SAC:997134, Description of Service :Motor Vehicle Insurance Services, Place of Supply :TAMIL NADU(State Code:33), Receipt No/Invoice No:33TA210000922
I/we hereby certify that the policy to which this certificate relates as well as this certificate of insurance are issued in accordance with the provisions of Chapter X and Chapter XI of Motor
Vehicle Act, 1988
For & On Behalf of Universal Sompo General Insurance Co. Ltd.

Authorized Signatory
In case of any claim or assistance required please contact our help line at 1800 209 0060 and you may also reach us at [email protected]
 Universal Sompo General Insurance Co. Ltd.
Servicing Office of Insurer: DOOR NO:47-1,GROUND FLOOR, OPPOSITE TO, IDBI
BANKDR.BALASUNDARAM ROAD, COIMBATORE, Coimbatore, Tamil Nadu (State Code:33) -641018,
PH-422-2221153 Website: www.universalsompo.com
PAN: AAACU8917F . GSTIN: 33AAACU8917F1ZD Insurer's IRDA Registration Number: 134
Tollfree Helpline 1800-200-4030 Email: [email protected] CIN :
U66010MH2007PLC166770
Passenger carrying Vehicle Package Policy (UIN-IRDAN134RP0004V02200708)
(FORM 51 OF THE CENTRAL MOTOR VEHICLE RULES, 1989)

Policy No. 2311/64957687/00/000 Policy Issued On 20-NOV-2021 (16:43)

Insured Name MRS. VINOTHINI R
Own Damage Period 22-NOV-2021(00:00) To 21-NOV-2022(Midnight) Motor Liability Period 22-NOV-2021(00:00) To 21-NOV-2022(Midnight)

Limitations as to use: The policy covers use of the vehicle for any purpose other than (1) Hire or Reward (2) Carriage of
goods (other than samples or personal luggage) (3) Organized racing (4) Pace making (5) Speed testing (6) Reliability trials
(7) Any purpose in connection with motor trade.

Driver¶s Clause: Any person including the insured: Provided that the person driving holds an effective driving license at
the time of the accident and is not disqualified from holding or obtaining such license. Provided also that the person holding
an effective learners license may also drive the vehicle & that such a person satisfies the requirements of Rule 3 of the
Central Motor Vehicle Rules, 1989.

Limits of Liability Clause:Under Section II-1(i) of the policy-Death of or bodily injury: Such amount as is necessary to
meet the requirements of the Motor Vehicle Act 1988.Under Section II-1 (ii) of the policy-Damage to third party property is
Rs.7.5lakhs PA Cover Under Section III for Owner-Driver is Rs. 1500000

NCB Clause: The insured is entitled for a No Claim Bonus (NCB) on the own damage section of the policy, if no claim is
made or pending during the preceding year(s)-20%, preceding two consecutive years-25%, preceding three consecutive
years-35%, preceding four consecutive years-45%, preceding five consecutive years-50% of NCB on OD Premium. NCB is
allowed provided the policy is renewed within 90 days of the expiry date of the previous policy.

Important Notice: The insured is not indemnified if the vehicle is used or driven otherwise than in accordance with the
schedule. Any payment made by the company by reasons of wider terms appearing in the certificate in order to comply with
the Motor Vehicle Act, 1988 is recoverable from the insured. See the clause headed ³AVOIDANCE OF CERTAIN TERMS
& RIGHT OF RECOVERY´For legal interpretation English version will hold good.

Note: This Schedule, the attached Policy and Endorsements mentioned herein above shall read together and word or
expression to which a specific meaning has been attached in any part of this policy or of the Schedule shall bear the same
meaning wherever it may appear. Any amendments/modifications/alterations made on this system generated policy
document is not valid and Company shall not be liable for any liability whatsoever arising from such changes. Any changes
required to be made in the policy once issued would be valid and effective, only after written request is made to the
Company and Company accepts the requested amendments/modifications/alterations and records the same through separate
endorsement to be issued by the company.
In Witness whereoff this policy has been signed at COIMBATORE on 20-NOV-2021 16:43
 Universal Sompo General Insurance Co. Ltd.
Servicing Office of Insurer: DOOR NO:47-1,GROUND FLOOR, OPPOSITE TO, IDBI
BANKDR.BALASUNDARAM ROAD, COIMBATORE, Coimbatore, Tamil Nadu (State Code:33) -641018,
PH-422-2221153 Website: www.universalsompo.com
PAN: AAACU8917F . GSTIN: 33AAACU8917F1ZD Insurer's IRDA Registration Number: 134
Tollfree Helpline 1800-200-4030 Email: [email protected] CIN :
U66010MH2007PLC166770
Passenger carrying Vehicle Package Policy (UIN-IRDAN134RP0004V02200708)
(FORM 51 OF THE CENTRAL MOTOR VEHICLE RULES, 1989)

Policy No. 2311/64957687/00/000 Policy Issued On 20-NOV-2021 (16:43)

Insured Name MRS. VINOTHINI R
Own Damage Period 22-NOV-2021(00:00) To 21-NOV-2022(Midnight) Motor Liability Period 22-NOV-2021(00:00) To 21-NOV-2022(Midnight)

PRIVATE CAR PACKAGE POLICY: ADD ON COVERS

Depreciation Waiver (Available upto 7 years)
In the case of an accident leading to a partial loss, there will be No depreciation charged on the cost of the parts to be
necessarily replaced.
Plans:
Plan A: The cover is applicable for every partial loss claim during the policy period.
Conditions:
1.Applicable only for repairs undertaken at designated authorized garages of manufacturers.
2.Obsolete vehicles shall not be eligible for the add-on cover.
Subject otherwise to the terms, conditions, limitations and exceptions of the policy.